Non-Descent Vaginal Hysterectomy Shalini Rajaram, Neerja Goel, Surveen Ghumman
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IntroductionChapter 1

2Hysterectomy is the commonest procedure performed in gynecology. Traditionally various routes for removal of the uterus have been used. Abdominal hysterectomy is undoubtedly the most popular with a 70:30 ratio for abdominal versus vaginal route.1,2 Laparoscopic assisted vaginal hysterectomy (LAVH) enjoyed its place in the last decade when it had become fashionable to perform a hysterectomy with the technically superior laparoscope. However, gynecologists were soon to learn that hysterectomy could be performed more easily, faster, with least complications and with excellent patient recovery when the vaginal route was used. In fact revival of this route must be attributed to the widespread use of the laparoscopic approach. Anyone who has performed LAVH will agree that majority of the procedure is accomplished vaginally! In fact some gynecologists condemn LAVH as a dangerous and unnecessary operation that is often substituted for vaginal hysterectomy.2 The latest randomized eVALuate study to evaluate the role of vaginal, abdominal and laparoscopic hysterectomy in routine gynecological practice concluded that major hemorrhage, hematoma, ureteric injury, bladder injury and anesthetic complications were more in the LAVH group when compared to abdominal and vaginal hysterectomies.3 In addition LAVH was accomplished in twice the time needed for a vaginal hysterectomy; 72 minutes versus 39 minutes.3
Despite documented evidence that the vaginal route is superior, why is it that gynecologists shy away from the vaginal route? Is it because abdominal hysterectomy with its large incision and easy access to the uterus is surgically more comfortable or is it because of physician reluctance to change or is it because of inadequate residency training? Kovac by the use of a statistical model in physician decision making showed that various factors such as residency training, personal experience, and surgical capability greatly influence the selection of abdominal versus vaginal hysterectomy. In their study they showed that physicians' seldom selected the vaginal route despite any clear indication for the abdominal route.4 Current evidence suggests that a physician's comfort and preference is the only consideration in selection of the type of hysterectomy performed!5 This despite documenting that abdominal hysterectomy for less serious conditions unnecessarily subjects women to greater risk of complications, longer recuperation and poorer postoperative quality-of-life outcomes.
It can be rightly said that the father of non-descent vaginal hysterectomy in modern India is certainly Sheth with his experience of 5655 vaginal hysterectomies (VH) done from 1967 to 2001.6 He did all hysterectomies, in private practice without laparoscopic assistance. A new concept proposed by him is the ‘trial vaginal hysterectomy’ where a surgeon feels that VH is possible but may prove 4difficult or fail and recourse to laparoscopy or laparotomy may be necessary. This puts the gynecologist in a comfortable position, as ‘failures’ can occur in certain situations like a large uterus, adnexal pathology, adhesions, etc. The technique requires only standard instruments and sutures and gaining expertise in NDVH would mean serving 80 percent of the world, i.e. developing countries better. Finally, Sheth believes that ‘marketing’ the procedure as ‘scarless surgery’ would make it more popular.
Non-descent vaginal hysterectomy is a more skilled procedure and has a learning curve, but nevertheless can be mastered provided the correct approach and technique is adopted. The purpose of this book is to shorten the learning curve by providing in-depth information of non-descent vaginal hysterectomy systematically and comprehensively in this ‘step-by-step’ manuscript and accompanying video of the basic and advanced technique.
REFERENCES
  1. Dorsey JH, Steinberg EP, Holtz PM. Clinical indications for hysterectomy route: Patient characteristics or physician preference. Am J Obstet Gynecol 1995;173:1452–60.
  1. Maresh MJ, Metcalfe MA, Mcpherson K, Overton C, Hall V, Hargreaves J et al. The value national hysterectomy study: Description of patients and their surgery. Br J Obstet Gynecol 2002;109:302–12.
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  1. 5 Kovac SR. Guidelines to determine route of hysterectomy. Obstet Gynecol 1995;85:18–23.
  1. Kovan SR. Clinical opinion: Guidelines for hysterectomy. Am J Obstet Gynecol 2004;191: 635–40.
  1. Sheth SS. The scope of vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol 2004;115:224–230.